1991, 06-25 Permit App: 91003612 Gas Log, PipingMECHANICAL PERMIT APPLICATION FORM
JOB STREET ADDRESS: S
CITY/STATE/ZIP:
Iriformation Worksheet
PARCEL NUMBER:
OWNER: J7� v PHONE NUMBER:
MAILING ADDRESS: s/" e -
(Street) (City/State) (Zip)
CONTRACTOR: A1Y/ '/>Z-->_�7yG, 0/7�/iVX *ff J LICENSE NUMBER: &i��62rg % (22"
_ �y PHONE NUMBER:
MAILING ADDRESS: �K ( A I2<-x7"71K HCl r'(
(Street) " (City/State) (zip)
MECHANICAL WORKSHEET/FEE SCHEDULE
NOTE: MINIMUM PERMIT FEE IS $35.00
SIGNATURE
NUMBER
OF UNITS
X EACH
UNIT
=AMOUNT
x 10.00 =
x 25.00 =
x 10.00 =
x 12.00 =
x 15.00 =
x 1.00 =
x 12.00 =
x 20.00 =
x 25.00 =
x 35.00 =
x 60.00 =
x 12.00 =
x 20.00 =
x 25.00 =
x 35.00 =
x 60.00 =
x 10.00 =
x 10.00 =
x 50.00 =
x 10.00 =
x 10.00 =
x 10.00 =
x 10.00 =
x 10.00 =
x 50.00 =
X100.00 =
x 50.00 =
X100.00 =
x 12.00 =
x 15.00 =
/
I
/
j
SUBTOTAL
$ i
PLUS: PROCESSING FEE
+ $ 25.00
EQUALS: TOTAL PERMIT
FEE DUE
_ $
Spokane County Division of Buildings
West 1303 Broadway Avenue Spokane, WA 99260 (509) 456-3675